Healthcare Provider Details

I. General information

NPI: 1114402427
Provider Name (Legal Business Name): ELETHIA MOORE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2018
Last Update Date: 05/03/2024
Certification Date: 05/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6801 LUCY CORR CT
CHESTERFIELD VA
23832-6657
US

IV. Provider business mailing address

6801 LUCY CORR CT
CHESTERFIELD VA
23832-6657
US

V. Phone/Fax

Practice location:
  • Phone: 804-768-7318
  • Fax:
Mailing address:
  • Phone: 804-768-7318
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number0024189825
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: